Adopting an American framework to optimize nursing admission documentation in an Australian health organization.

Objective: Apply and modify the American Essential Clinical Dataset (ECD) approach to optimize the data elements of an electronic nursing admission assessment form in a metropolitan Australian local health district.

Materials And Methods: We used the American ECD approach but made modifications. Our approach included (1) a review of data, (2) a review of current admission practice via consultations with nurses, (3) a review of evidence and policies, (4) workshops with nursing and informatics teams in partnership with the electronic medical record (eMR) vendor, and (5) team debrief sessions to consolidate findings and decide what data elements should be kept, moved, or removed from the admission form.

Bringing the Nurse Back to the Bedside.

As digitisation continues to increase across Australian health services, the nursing profession has focused on analysing and measuring the way care is provided to the patients. Focus on optimising nursing workflows and improved care delivery has presented challenges but this is now demonstrating improvements in patient care outcomes and time for care.